Comet tail artifact on ultrasonography: is it a reliable finding of benign gallbladder diseases?

PURPOSE: The aim of this study was to evaluate whether the comet tail artifact on ultrasonography can be used to reliably diagnose benign gallbladder diseases. METHODS: This retrospective study reviewed the clinical findings, imaging findings, preoperative ultrasonographic diagnoses, and pathological diagnoses of 150 patients with comet tail artifacts who underwent laparoscopic cholecystectomy with pathologic confirmation. The extent of the involved lesion was classified as localized or diffuse, depending on the degree of involvement and the anatomical section of the gallbladder that was involved. This study evaluated the differences in clinical and imaging findings among pathologic diagnoses. RESULTS: All gallbladder lesions exhibiting the comet tail artifact on ultrasound examination were confirmed as benign gallbladder diseases after cholecystectomy, including 71 cases of adenomyomatosis (47.3%), 74 cases of chronic cholecystitis (49.3%), two cases of xanthogranulomatous cholecystitis (1.3%), and three cases of cholesterolosis (2.0%); there were two cases of coexistent chronic cholecystitis and low-grade dysplasia. There were no statistically significant differences in any of the clinical and ultrasonographic findings, with the exception of gallstones (P=0.007), among the four diseases. There were no significant differences in the average length, thickness, or number of comet tail artifacts among the four diagnoses. No malignancies were detected in any of the 150 thickened gallbladder lesions. CONCLUSION: The ultrasonographic finding of the comet tail artifact in patients with thickened gallbladder lesions is associated with the presence of benign gallbladder diseases, and can be considered a reliable sign of benign gallbladder disease.

Unrecognised IgG4 association in progressively transformed germinal centers of lymph nodes with subsequent full-blown IgG4-related chronic fibrosing pancreatitis: A case report

Progressively transformed germinal centers (PTGC) is a benign process characterised by a morphological variant of reactive follicular hyperplasia in lymph nodes. It was recently shown that some cases of PTGC are associated with IgG4-related disease (IgG4-RD) or increased IgG4 plasma cells. Five years ago, a 57-year-old woman presented with enlargement of multiple lymph nodes in the left parotid, submandibular, and neck areas, pathologically diagnosed as PTGC after excisional biopsy. Since then, she has experienced numbness in her extremities, especially the left shoulder and arm, pruritus on the left side of the face and intermittent facial palsy, for which she has been receiving regular symptomatic treatment. Recently the patient developed diabetes mellitus (approximately seven months ago). In routine follow-up scans, a mass was detected in left kidney and magnetic resonance imaging of the abdomen prior to surgery revealed a slightly enhanced bulky mass replacing the pancreatic tail and uncinate process. The mass in left kidney was diagnosed as clear cell renal cell carcinoma, and the pathological features of the pancreatic lesion were those of IgG4-related chronic fibrosing pancreatitis. Retrograde examination of the neck lymph node diagnosed as PTGC showed increased deposition of IgG4-positive plasma cells.

Dynamic Contrast-Enhanced CT Findings of a Extrapleural Solitary Fibrous Tumor in the Spleen: A Case Report and Literature Review

Extrapleural solitary fibrous tumor, formerly referred to as “hemangiopericytoma” is a rare soft tissue vascular tumor which has elevated malignancy potential arising from the capillary pericytes. Extrapleural solitary fibrous tumors, originating from the spleen, are extremely rare. We report on a rare case of a patient presenting with splenic extrapleural solitary fibrous tumors with intratumoral irregular calcification detected by dynamic contrast-enhanced computed tomography.

Detection of Recurrent/Residual Hepatocellular Carcinoma: Single-Center Retrospective Comparative Study Between Parenchymal Blood Volume Mapping Using Cone Beam CT and Multiphase Dynamic CT

PURPOSE@#To evaluate the usefulness of cone beam computed tomography (CT)-based parenchymal blood volume (PBV) mapping for the detection of marginal recurrence or residual hepatocellular carcinoma, after transcatheter arterial chemoembolization (TACE), and to compare it with multiphase dynamic CT (MDCT).@*MATERIALS AND METHODS@#From March 2015 to October 2016, 26 patients with 49 iodized nodules who underwent TACE and a pre-interventional MDCT scan were enrolled in our study. We evaluated the diagnostic efficacies of PBV mapping using cone beam CT and MDCT in the detection of marginal recurrences or viable tumors.@*RESULTS@#The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of PBV mapping and MDCT were 100%, 96.7%, 94.7%, and 100%, and 77.9%, 93.5%, 87.5%, and 87.8%, respectively. The overall sensitivity for identifying local marginal recurrence was higher for PBV mapping than for MDCT (p < 0.005). The performances of PBV mapping and MDCT in the diagnosis of local marginal recurrence were significantly different (p = 0.037, McNemar test).@*CONCLUSION@#Compared with MDCT, PBV mapping can significantly increase the detection of marginal recurrence or residual tumor after TACE because it is free of beam-hardening artifact. PBV mapping should be considered as a feasible modality-related tool for patients who have undergone chemoembolization.

Hepatic perivascular epithelioid cell tumor (PEComa): a case report with a review of literatures

Hepatic perivascular epithelioid cell tumors (PEComas) are very rare. We report a primary hepatic PEComa with a review of the literature. A 56-year-old women presented with a nodular mass detected during the management of chronic renal failure and chronic hepatitis C. Diagnostic imaging studies suggested a nodular hepatocellular carcinoma in segment 5 of the liver. The patient underwent partial hepatectomy. A brown-colored expansile mass measuring 3.2×3.0 cm was relatively demarcated from the surrounding liver parenchyma. The tumor was mainly composed of epithelioid cells that were arranged in a trabecular growth pattern. Adipose tissue and thick-walled blood vessels were minimally identified. A small amount of extramedullary hematopoiesis was observed in the sinusoidal spaces between tumor cells. Tumor cells were diffusely immunoreactive for human melanoma black 45 (HMB45) and Melan A, focally immunoreactive for smooth muscle actin, but not for hepatocyte specific antigen (HSA).

Gastrointestinal Stromal Tumor of the Stomach Presenting as Multilobular with Diffuse Calcifications

Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract and usually appear as a well-circumscribed mass. However, it may be difficult to confirm the extent of the disease for some GISTs. A 70-year-old asymptomatic female presented for a regular physical exam. An esophagogastroduodenoscopy showed a 2.0 cm protruding mass on the gastric fundus. Endoscopic ultrasound revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm). A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus. Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT. Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin. Final pathologic diagnosis was an intermediate risk GIST in multilobular form. In patients with diffuse multifocal calcifications in the stomach, the possibility of GIST should be considered.

A Case of Giant Colonic Muco-submucosal Elongated Polyps Associated with Intussusception

Colonic muco-submucosal elongated polyp (CMSEP), a newly categorized non-neoplastic colorectal polyp, is a pedunculated and elongated polyp composed of normal mucosal and submucosal layers without any proper muscle layer. We herein report a giant variant of CMSEP associated with intussusception in the rectosigmoid colon, with a review of the literature. A 48-year-old woman underwent a laparoscopic low anterior resection due to multiple large submucosal polypoid masses associated with intussusception. Grossly, the colonic masses were multiple pedunculated polyps with a long stalk and branches ranging in size from a few millimeters to 14.0 cm in length. Microscopically, there was no evidence of hyperplasia, atypia, or active inflammation in the mucosa. The submucosal layers were composed of edematous and fibrotic stroma with fat tissue, dilated vessels, and lymphoid follicles.

A Case of Long-Term Complete Remission of Advanced Gastric Adenocarcinoma with Liver Metastasis

We report the case of a patient with gastric adenocarcinoma with multiple liver metastases. This patient showed complete remission for more than 68 months after S-1/cisplatin combination chemotherapy and radical total gastrectomy. The patient, a 63-year-old man, presented with dyspepsia and difficulty in swallowing. Endoscopic findings showed a huge ulcero-infiltrative mass at the lesser curvature of the mid-body, extending to the distal esophagus. Biopsy revealed a poorly differentiated tubular adenocarcinoma. An abdominal computed tomography scan demonstrated multiple hepatic metastases. S-1/cisplatin combination chemotherapy was initiated, and following completion of six cycles of chemotherapy, the gastric masses and hepatic metastatic lesions had disappeared on abdominal computed tomography. Radical total gastrectomy and D2 lymphadenectomy combined with splenectomy were performed. The patient underwent three cycles of S-1/cisplatin combination chemotherapy followed by tegafur-uracil therapy for 1 year. He remained in complete remission for more than 68 months after surgery.

Ultrasonographic differentiation of bezoar from feces in small bowel obstruction

PURPOSE: To evaluate ultrasonographic accuracy in the differentiation of a bezoar from feces in a small bowel obstruction showing feces-like material just proximal to the transitional zone in abdominal computed tomography (CT). METHODS: This study included 14 patients who showed feces-like material just proximal to the transitional zone, among 302 patients diagnosed with small bowel obstruction on abdominal CT. The diagnostic signs of a bezoar on ultrasonography included an arc-like surfaced intraluminal mass, posterior acoustic shadow and twinkling artifacts. The diagnostic performance of ultrasonography in each patient was compared with a final diagnosis that was surgically or clinically made. RESULTS: Among the 14 patients, seven were ultrasonographically diagnosed as having a bezoar, and five of the seven were surgically diagnosed as having a phytobezoar. The remaining two of the seven showed complete symptomatic improvement before surgery. The other seven patients were ultrasonographically diagnosed as not having a bezoar. Among them, six patients were conservatively treated with symptomatic improvement, suggesting the absence of a bezoar. The remaining one patient was confirmed not to have a bezoar during adhesiolysis. In all patients, the ultrasonographic diagnosis agreed with the clinically confirmed diagnosis. CONCLUSION: Ultrasonography might be an accurate method for the differential diagnosis of feces-like material just proximal to the transitional zone in abdominal CT. It can help radiologists to quickly and easily diagnose a bezoar.

An unusual case of candidemia presenting as acute respiratory distress syndrome after a small bowel bezoar removal operation

We report a rare case of sepsis with acute respiratory distress syndrome (ARDS) caused by Candida parapsilosis and Candida famata after a small bowel bezoar operation. The patient was successfully treated with intensive care including mechanical ventilation and systemic antifungal therapy. A strong association was observed between the intestinal obstruction caused by the bezoar and candidemia presenting as ARDS. This is the first case in which candidemia has led to ARDS after a bezoar removal operation in a patient who was neither immunocompromised nor self-administering an illicit intravenous drug.

Laparoscopic Resection of Retrocaval Non-functioning Paraganglioma

Retroperitoneal paraganglioma is located prim arily at the para-aortic area and functioning tumor, however, non-functioning and retrocaval located tumors are rare. Laparoscopic retrocaval paraganglioma resection is technically challenging due to vena cava close relation. A 49-year-old male was referred for a retroperitoneal tumor, detected by FDG-PET scan. He had undergone right thyroidectomy for papillary carcinoma one year ago. Abdominal computed tomography (CT) scan showed a mass measuring 2 cm in size located behind the inferior vena cava (IVC), which deviate IVC anteriorly. I123-metaiodobenzylguanidine (MIBG) scan also demonstrated abnormal focal activity. Result of preoperative adrenal function test was normal. A laparoscopic retrocaval tumor excision was performed successfully. The operative time was 160 minutes. The patient's postoperative recovery was uneventful and he was discharged on the fourth postoperative day. Pathologic examination was consistent with the diagnosis of paraganglioma. To the best of our knowledge, this is the first report on laparoscopic resection of a retrocaval non-functioning paraganglioma. In conclusion, laparoscopic retrocaval paraganglioma resection is safe and feasible.

Giant cavernous hemangioma coexistent with diffuse hepatic hemangiomatosis presenting as portal vein thrombosis and hepatic lobar atrophy

A combination of giant hepatic hemangioma and diffuse hemangiomatosis is extremely rare in adults. Even when they are large, hemangiomas are soft and rarely compress adjacent structures. A 78-year-old man presented with abdominal pain and distension. Ultrasonography, computed tomography, and magnetic resonance imaging demonstrated a large expansile mass replacing the medial segment and caudate lobe with diffusely scattered nodules in the entire liver. The large hilar mass contained a central nonenhancing area and had a mass effect, leading to left portal vein occlusion. The image findings also revealed two unprecedented findings: left lateral segmental atrophy of the liver and recent portomesenteric vein thrombosis. The hepatic lesions were confirmed with hemangiomas by ultrasonography-guided biopsy. We diagnosed intrahepatic portal vein obstruction caused by a mass effect of giant hepatic hemangioma coexistent with diffuse hemangiomatosis, resulting in hepatic segmental atrophy and extrahepatic portal vein thrombosis.

A giant retroperitoneal lymphangioma in a patient with neurofibromatosis type 1 / 대한외과학회지

Neurofibromatosis type 1 (NF-1) is a genetically inherited disorder that may cause skin abnormalities and tumors that form on nerve tissues. These tumors can be small or large and can occur anywhere in the body, including the brain, spinal cord, or other peripheral nerves. Retroperitoneal lymphangiomas are very rare benign malformations of the lymphatic system. About 95% lymphangiomas occur in the skin and the subcutaneous tissues of the head, neck and axillary region and the remaining 5% appear in other parts of the body such as lungs, pleura, pericardium, liver, gallbladder, kidney, and the mesentery. Herein, we report the case of a giant retroperitoneal lymphangioma in a patient with NF-1 with a review of the literature.

Isolated Dissection of Superior Mesenteric Artery: Study on the Treatment Guidelines

PURPOSE: Isolated superior mesenteric artery (SMA) dissection is a rare, but increasing vascular disorder. However, optimal treatment guidelines are not well established. The purpose of this study is to review a single institutional experience in the management of isolated SMA dissections and establish optimal treatment guidelines. METHODS: Between November 2004 and August 2009, 26 patients were diagnosed with isolated SMA dissection at Eulji University Hospital. Diagnosis was confirmed with CT scans in all patients. We retrospectively reviewed the medical records, imaging studies, and the early outcomes of the patients. RESULTS: There were 22 (84.5%) men and 4 women. The mean age was 55.4 (39~74) years. The mean follow-up was 39.1 (4.1~53.3) months. In 15 patients, CT scans were performed for abdominal pain, and in the other 11 patients, the isolated SMA dissections were detected incidentally during workup for other causes. The radiographic findings included an intimal flap with a patent false lumen in 16 and intramural hematoma in 10. The dissection started at a mean of 22.3 (5~46) mm from the origin of the SMA with a mean length was 47.7 (10~150) mm. Treatments included expectant management in 13, anticoagulation in 6, stenting in 6 patients, and surgery in one case of bowel infarction. None required additional intervention. All patients remained asymptomatic during follow-up. CONCLUSION: Most patients with isolated SMA dissection were successfully managed medically. Surgical or percutaneous intervention should be reserved for those with evidence of bowel necrosis or mesenteric ischemia and failed cases to initial medical treatment.

Ureteral Sciatic Hernia: A Case Report

A ureteral hernia that occurs through the sciatic foramen is very rare. We present a case of a ureteral sciatic hernia with hydronephrosis. Intravenous urography (IVU) showed the presence of a curved, laterally displaced ureter, and computed tomography (CT) clearly depicted the herniated ureter through the sciatic foramen. The patient was treated transiently with a double J catheter.

Clinical feature of Fitz-Hugh-Curtis syndrome: Analysis of 25 cases / 대한간학회지

BACKGROUND/AIMS: Fitz-Hugh-Curtis syndrome is defined as perihepatitis associated with pelvic inflammatory disease (PID). We retrospectively analyzed clinical and laboratory manifestations as well as the therapeutic response in patients with clinically diagnosed Fitz-Hugh-Curtis syndrome. METHODS: A cohort of 25 patients with PID and perihepatitis (as diagnosed by dynamic abdominal computed tomography (CT)) was enrolled. The prognosis, clinical manifestations, and physical examination, laboratory, and CT findings were analyzed. RESULTS: The mean (+/-SD) age of the patients was 32(+/-8) years, and all of them were sexually active, premenopausal women, and presented with abdominal pain. Of these, 52% complained of vaginal discharge. On physical examination, right upper-quadrant tenderness was the most common finding (84%), with lower-abdominal tenderness being present in 20% of patients. On laboratory examination, erythrocyte sedimentation rate and C-reactive protein were increased in 76% and 92% of the patients, respectively. The white blood cell count was increased in 60% of them. Most patients had a normal liver function test. Using a specimen of the cervical discharge, the polymerase chain reaction to test for Chlamydia trachomatis were positive in 87% (13/15) of the patients, and Chlamydia antigen was found in 75% (9/12) of them. Dynamic abdominal CT revealed subcapsular enhancement of the liver in the arterial phase. All of the patients improved with antibiotic therapy. CONCLUSIONS: Symptoms and physical findings suggestive of PID are not present in many patients with Fitz-Hugh-Curtis syndrome. When a premenopausal woman complains of upper abdominal pain and shows CT findings compatible with perihepatitis, examination of cervical discharge would be recommended to assess the possibility of Fitz-Hugh-Curtis syndrome.

A Case of End-Stage Renal Disease (ESRD) from Reflux Nephropathy in a patient with Situs Inversus and Duplicated Ureter / 대한신장학회지

Situs inversus is a rare congenital anomaly that occurs in adults at the rate of 1:5,000-1:10,000. In the total form, the thoracic organs, as well as the abdominal organs, are completely reversed in a "mirror image" of their normal arrangements. Ureteral duplication is the most common ureteral anomaly founded incidentally. However, there is a higher incidence of duplication in cases of urinary tract infection, and it may be associated with upper urinary tract stasis, obstruction, or reflux. But ureteral duplication has no relation to situs inversus. Vesicoureteral reflux (VUR) is the most common disorder usually detected during radiologic evaluation of children with urinary tract infection. Complications such as renal scarring, reflux nephropathy, chronic renal failure and hypertension are well known in patients with VUR. Reflux nephropathy is responsible for about 10% of all cases of treated ESRD and is the most common case of ESRD in children. Thus, if VUR exists, early diagnosis and intensive treatment is necessary. Herein, we present a case of reflux nephropathy related ESRD in a 41-year-old woman with total situs inversus and duplicated ureter.

Celiomesenteric Trunk with Concurrent Common Hepatic Artery Aneurysm: A Case Report

Celiomesenteric trunk is a rare anomaly, and its co-occurrence with an aneurysm is even more unusual. We present a case of celiomesenteric trunk with a concurrent hepatic arterial aneurysm, both of which were found incidentally on screening abdominal ultrasonography.

Tuberculous Liver Abscess in a Patient on Continuous Ambulatory Peritoneal Dialysis / 대한신장학회지

The incidence of tuberculosis (TB) in patients on regular hemodialysis and continuous ambulatory peritoneal dialysis (CAPD) patients is higher than that of general population. But, tuberculous liver abscess is rare even in endemic area and is found in 0.34% of hepatic tuberculosis. Extrapulmonary tuberculosis shows atypical presentation, and prompt diagnosis and treatment is important for prognosis of the patient. We report a case of CAPD patient with primary tuberculous liver abscess. The patient was treated successfully with antituberculous therapy after the diagnosis was established by histopathologic examination from the specimen obtained by ultrasound-guided percutaneous biopsy of the liver.

Preliminary Experience of Multidetector Computed Tomography(MDCT) Cholangiography using Thin-Slab Minimum Intensity Projection (MinIP) and Multiplanar Reformation(MPR) in the Evaluation of Patients with Biliary Obstruction

PURPOSE: The development of MDCT and associated software has enabled us to obtain clear biliary images. This study aimed to investigate the preliminary experience and use of MDCT cholangiography using MinIP and MPR for preoperative planning. METHODS: We reviewed MDCT cholangiographies of 11 patients who underwent surgery due to a biliary obstruction in our hospital between May 2004 and July 2005. The CT scan used 16 channels. The axial images were routinely reconstructed at 5 mm intervals. If the bile ducts were dilated as seen on the axial images, portal phase raw data (with a collimation of 0.75 mm) were reconstructed at 0.5 mm intervals for MDCT cholangiography using MinIP and MPR. We analyzed the images and compared them with the surgical findings. RESULTS: Of 11 patients, 8 patients underwent a pylorus preserving pancreaticoduodenctomy, one patient underwent a hepatopancreaticoduodenectomy, one patient had a segmental resection of the bile duct, and one patient received a pancreatic head resection and segmental duodenectomy. MDCT cholangiographies showed an enhancement of wall thickening in the lesion of the bile duct, especially with extrahepatic bile duct cancer. The MDCT cholangiographies were able to provide the correct level and range of the biliary obstruction and were useful for preoperative planning. CONCLUSION: MDCT cholangiography using thin-slab MinIP and MPRprovided useful information for the diagnosis of patients with malignant biliary obstruction and was well correlated with other cholangiographies. With technical advances in MDCT and three dimensional projection techniques, CT cholangiography may supplant other procedures such as diagnostic endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC) and magnetic resonance cholangiopancreatography (MRCP) because of its superior resolution and ability to provide pertinent information for the evaluation of the biliary tract and the surrounding structures.